Respiratory monitoring is a prerequisite for safe noninvasive ventilation

Neinvazivna ventilacija (NIV) je učinkovit način respiracijske potpore za dio bolesnika sa zatajenjem disanja. Pravovremenom primjenom NIV-a kod dijela bolesnika može se izbjeći invazivna ventilacija i njezini neželjeni učinci, čime se skraćuje vrijeme provedeno u Jedinici intenzivnog liječenja (JIL). U zadnjih dvadeset godina bilježi se učestalija primjena NIV-a, a povećava se i broj indikacija kod kojih se NIV pokazao kao metoda izbora. Tijekom pandemije COVID-19 NIV je postao vrlo popularan i kod bolesnika sa zatajenjem disanja u sklopu infekcije COVID-19 primjenjivan je diljem svijeta. Cilj rada je istaknuti nužnost respiracijskog nadzora za sigurnu primjenu NIV-a te upozoriti kliničare koji primjenjuju NIV u svakodnevnom radu na važnost uočavanja ubrzanog disanja i velikoga inspiracijskog napora kao kliničkih pokazatelja velikoga dišnoga rada. Neovisno o primarnom uzroku plućnoga oštećenja, veliki dišni rad dodatno pogoršava zatajenje disanja putem „samoozljeđivanja“ pluća (engl. patient self inflicted lung injury, P-SILI). Istaknuti su pokazatelji respiracijskog nadzora koji neizravno ukazuju na opasnost od P-SILI, a to su: veliki volumeni udisaja (engl. tidal volume, VT), negativni pomaci na krivulji alveolarnoga tlaka (engl. alveolar pressure, Paw), povećane vrijednosti okluzijskog tlaka u dišnome putu (P0.1) te visoke vrijednosti „driving“ tlaka. Smanjenje i kontroliranje velikoga dišnoga rada izazov je u svim situacijama u kojima bolesnik spontano diše, neovisno je li na neinvazivnoj ili invazivnoj potpori disanja. Temeljem do sada objavljenih spoznaja, kao i iz osobnih iskustava stečenih dugogodišnjom primjenom NIV-a u različitim kliničkim indikacijama, nastojali smo sažeti moguće načine kontrole povećanoga dišnog rada. Samo striktnim nadzorom respiracijskih pokazatelja, kontrolom povećanoga dišnog rada i poznavanjem NIV-a kao metode potpore disanja njegova primjena postaje sigurna, a eventualni neuspjeh NIV-a i potreba za prijelazom na invazivnu ventilaciju bit će na vrijeme prepoznata.Noninvasive ventilation (NIV) is an effective respiratory support for some patients with respiratory failure. Timely NIV application can help some patients avoid invasive mechanical ventilation (IMV) and its adverse effects, and thus shorten their length of stay in the ICU. NIV use became more frequent during the last 20 years and has been proven as a method of choice for a number of indications. NIV became very popular during the COVID-19 pandemic and was used all over the world. Main goals of this paper are to emphasize respiratory monitoring as a prerequisite for safe NIV application and to warn clinicians of the importance of high respiratory rate and huge inspiratory effort as clinical signs of high work of breathing (WOB). Regardless of the primary cause of lung injury, high WOB further impairs respiratory failure by self-inflicted lung injury (P-SILI). Indirect signs of high WOB, such as high tidal volume (VT), negative swings on airway pressure curve (Paw), high airway occlusion pressure (P0.1) and high driving pressure are discussed as predictors of P-SILI. High WOB attenuation and its control is challenging in all spontaneously breathing patients, whether their respiratory support is invasive or noninvasive. Based on published knowledge and our own experience during long lasting NIV use in different clinical situations, we tried to point out options for high WOB control. NIV is safe only under conditions of strict respiratory monitoring, high WOB control and good knowledge of NIV as a method of respiratory support. In such cases NIV failure will be recognized and a switch to IMV will be performed on time

How can we use Intelligent mechanical ventilation to improve patient care in Intensive care unit?

Usprkos tomu što je mehanička ventilacija jedan od osnovnih postupaka spašavanja života u jedinicama intenzivne medicine, danas je nakon mnogih provedenih istraživanja jasno da pogrešno primijenjena mehanička ventilacija može napraviti značajnu štetu na ranije zdravim plućima ili pogoršati ozljedu bolesnih pluća te se u modernom pristupu ventilaciji maksimalno individualizira pristup, odnosno mehaničku ventilacija se individualno prilagođava stanju pluća pojedinog bolesnika. Usprkos tomu što postoje znanstveno dokazane metode smanjenja plućne ozljede, studije su pokazale da se u praksi kod velikog broja bolesnika one ne primjenjuju, odnosno ne mjere se parametri bitni za njihovo određivanje. Za individualizaciju ventilacije od intubacije do ekstubacije potrebno je nekoliko elementarnih alata kod kojih nam može pomoći umjetna inteligencija. To su incijalna optimizacija pozitivnog tlaka na kraju ekspirija, evaluacija i primjena manevara ponovog otvaranja kolabiranih dijelova pluća (engl. lung recruitment maneuver – RM), primjena moda ventilacije koji se može od udaha do udaha adaptirati na stanje bolesnikovih pluća, optimizacija plinova u krvi, optimizacija sinkronizacije bolesnika i ventilatora automatskim praćenjem krivulja mehaničke ventilacije te u konačnici alat za kvalitetnu procjenu sposobnosti bolesnika za odvajanje i samostalno disanje uz analizu potencijalnih problema kod odvajanja i njihove korekcije. To je moguće postići kombinacijom više alata, kao što su npr. alat tlak-volumen (engl. pressure – volume tool – PV-tool) uz ezofagealno mjerenje tlaka, adaptivna suportivna ventilacija (ASV) + Intellivent-ASV kao mod disanja, Intellisync+ te alat za olakšano odvajanje od respiratora (engl. quick weaning tool [QuickWean]) i test spontanog disanja (engl. spontaneous breathing trial – SBT) dostupni na uređajima za mehaničku ventilaciju. Kombinacijom ovih alata moguće je inicijalno optimizirati mehaničku ventilaciju, a zahvaljujući automatiziranoj pametnoj tehnologiji i individualizirati praktički svaki udah bolesnika te na minimum smanjiti vrijeme potrebno za pripremu odvajanja bolesnika od mehaničke ventilacije te ekstubaciju, a u konačnici i smanjiti smrtnost bolesnika na mehaničkoj ventilaciji.Despite the fact that mechanical ventilation is one of the main life saving procedures in the intensive care unit, after many conducted studies it is clear that if applied in the wrong way it can cause a lot of damage to the otherwise healthy lung or aggravate lung injury. Keeping this in mind, a modern approach to mechanical ventilation is to maximize individual approach to each patient, meaning to tailor mechanical ventilation to individual patient’s condition. Despite clear results from the studies proving some methods can lead to less lung injury, other studies have shown that in everyday clinical practice these methods are not being applied and parameters needed to calculate them are not being regularly measured. Individualizing mechanical ventilation in our patients from intubation to extubation means using several basic tools with which artificial intelligence can be very helpful. This includes initial optimization of positive end-expiratory pressure, evaluation/application of recruitment maneuvers, using a ventilatory mode capable of constantly adapting to the patients lung condition, optimization of lung gases, optimization of patient-ventilator synchronization by constant monitoring of the ventilatory curves and finally a quality tool to assess weaning readiness and spontaneous breathing with the analysis of potential problems in this phase and their correction. To achieve all the purposes, it is necessary to use a combination of tools including for example pressure volume tool (PV-tool) plus esophageal pressure measurement, adaptive support ventilation (ASV) plus Intellivent-ASV, Intellisync+ and an enhanced weaning tool (QuickWean) with added spontaneous breathing trial (SBT) tool available on the ventilator. Thanks to the smart technology, by combining these tools it is possible to practically individualize and optimize every breath, and thereby reduce total time on mechanical ventilation as well as weaning procedure time, to facilitate extubation, and in the end to reduce mortality on mechanical ventilation

Usporedba sevofluranske anestezije i TIVA-e s obzirom na hemodinamske i biokemijske pokazatelje funkcije srca nakon velikih abdominalnih operacija

A lot of surgical patients with colorectal cancer are older patients, often with a significant coexisting cardiac disease. Despite improvements in surgery and anesthesiology, postoperative morbidity and mortality in this group of patients have changed little during the last decade. Clinical studies of myocardial preconditon with a volatile anesthetic, especially with sevofluran, have identified beneficial effects in a group of cardiac surgery patients. Based on these facts, this study has investigated the influence of volatile anesthesia with sevofluran on perioperative cardiac function and occurance of ischemic events in abdominal surgery patients. 80 surgical patients with colorectal cancer, undergoing elective abdominal surgery, were devided in two groups. 42 patients in the first group were anesthetized with sevoflurane-balanced anethesia, 38 patients in the second group with a total intravenous anesthesia. Investigation was approved by Ethic committee of General hospital “Dr. Josip Benčević” and Ethic committee of Medical school of University in Zagreb. All patients were given written informed consent. Categorical data was tested with the chi-squared and Fisher′s exact test and continuous data was tested with the Mann-Whitney U test. Groups were comparable regarding sex, age and cardiac risk index. Troponin I and CKMb were analyzed, as well as cardiac index, cardiac function index and BNP, which represent cardiac ischemic injury and cardiac disfunction, respectively. Heat shock protein (HSP 70) was analyzed as a mediator of the preconditioning process and unspecific response of the cells to stress. There were recorded ICU days, hospital days and hospital mortality as endpoints. There were no statistic differences between groups regarding Troponin I and CKMb level during perioperative period. During the perioperative period 7,1% of patients in the sevoflurane group and 2,6 patients in the TIVA group had myocardial ischemia. Most patients were ischemic 4 hours after the onset of the operation. There were no statistic differences regarding hemodynamic variables CI and CFI between the groups. BNP level has raised in both groups of patients after 24 hours, but with no significant difference. The level of HSP 70 has almost doubled after 24 hours in both groups of patients, but with no signifficant difference between the investigated groups. It suggests that surgical stress has caused synthesis of HSP 70, with no influence of the anesthesia technique. There were no significant differences between the groups regarding hospital stay, ICU stay and hospital mortality. The results of our study didn′t confirm the preconditioning effect of sevoflurane, which was observed in cardiac surgery patients. The small number of patients in connection with the possibility of unfavourable cardiac events is the limitation of this study. But nevertheless results are a valuable contribution to a better insight into clinical relevance of the preconditioning phenomenon in general surgical patient

Stresni proteini

Stress proteins (also known as heat shock proteins) regulate fundamental cellular processes, such as protein folding, sorting, degradation, translocation and assembly, playing an important role in cell signaling, cytoskeletal organisation, apoptosis, antigen presentation, cell migration, proliferation and adhesion. Heat shock proteins are divided into families based on molecular mass: small, hsp40-60, hsp70, hsp90, hspllO. The best characterized family is hsp70 familiy. Hsp70 is induced by a number of stress stimuli, and its expression is regulated at transcriptional level by heat shock factor. There are many potential medical application of stress response, from cardiovascular diseases and graft preservation to immunotherapy of cancer

INVASIVE TRICHOSPORONOSIS CAUSED BY TRICHOSPORON ASAHII IN A POLYTRAUMATIZED NEUROSURGICAL PATIENT: CASE REPORT

Trichosporon asahii (T. asahii), nekadašnjeg naziva Trichosporon beigelli, rijedak je uzročnik infekcija u ljudi, s vrlo šarolikim kliničkim manifestacijama koje variraju od površinskih infekcija kože pa sve do teških sistemskih bolesti. T. asahii, oportunistička patogena gljiva, izuzetno je opasna za granulocitopenične, imunokompromitirane i imunodeficijentne bolesnike kojima može ugroziti život. Smatra se uzročnikom ljetnog, hipersenzitivnog pneumonitisa u Japanu i izaziva sistemske infekcije transplantiranih bolesnika, bolesnika na kortikosteroidnoj terapiji, bolesnika sa solidnim tumorima i bolesnika s opeklinama. Međutim, u literature su opisani i rijetki slučajevi infekcije tim patogenom u imunokompetentnih, kirurških bolesnika i bolesnika koji dugo leže JIL-u. Prikazujemo bolesnika od invazivne trihosporonoze uzrokovane T. asahii, s ishodištem infekcije u mokraćnom sustavu kateteriziranog, dugo ležećeg, neurokirurškog bolesnika. Gljiva slična kvascima izolirana je iz urina i krvi bolesnika tijekom ponovljene hospitalizacije na neurokirurškom odjelu, na koji je primljen zbog pogoršanja općeg stanja za vrijeme boravka na rehabilitaciji u specijaliziranoj ustanovi. U Referalnom centru za sustavne mikoze, HZZJZ, Zagreb, soj iz urina i hemokulture identificiran je kao T. asahii, dobro osjetljiv na flukonazol, vorikonazol i 5-fluorocitozin, smanjene osjetljivosti na itrakonazol i rezistentan na amphotericin B. Uz terapiju flukonazolom (400 mg/dan), provedena je i mjera zamjene urinarnog katetera urinarijem, te je bolesnik odlično odreagirao na navedene postupke. Iako se sistemska trihosporonoza uglavnom povezuje s imunokompromitirajućim stanjima kod ljudi (hematološke maligne bolesti, granulocitopenija, AIDS), ovaj slučaj ukazuje na mogućnost nastanka infekcije kod dugo ležećih bolesnika, kompromitirane lokalne imunosti zbog prisutnosti stranih tijela i dugotrajne antimikrobne terapije. Prikazani bolesnik je prvi dokumentirani slučaj trihosporonoze u ne klasično imunokompromitiranog bolesnika na području Hrvatske.Trichosporon asahii (formerly T. beigelii) is a rare cause of human infections with very varied clinical manifestations ranging from superficial infections to severe and systemic diseases. T. asahii is a life-threatening opportunistic pathogen especially for granulocytopenic, immunocompromised and immunodeficient patients. It is the possible cause of summer-type hypersensitivity pneumonitis in Japan and systemic infections in transplant patients, patients on corticosteroid therapy, patients with solid tumors and burn patients. Cases of infection in non-immunocompromised surgical patients and patients with long-term stay in ICU are described in the literature. We report on T. asahii fungemia in a polytraumatized neurosurgical patient with long-term stay in the hospital. Urinary tract was the source of fungemia, with the same pathogen isolated from urine and blood at the same time. In the Referral Center for Systemic Mycoses, Croatian Institute of Public Health, Zagreb, the strain from the urine and blood culture was identified as T. asahii, with good susceptibility to fluconazole, voriconazole and 5 fluorocytosine, reduced susceptibility to itraconazole and resistance to amphotericin B. The patient responded to fluconazole therapy very well. Since systemic trichosporonoses are generally associated with immunocompromised patients (hematologic, granulocytopenic and AIDS patients), thiscase confirms the possibility of infection with this pathogen in patients with long-term hospital stay and reduced local immunity, but without classic immunodeficiency

Respiracijski monitoring je preduvjet za sigurnu primjenu neinvazivne ventilacije

Neinvazivna ventilacija (NIV) je učinkovit način respiracijske potpore za dio bolesnika sa zatajenjem disanja. Pravovremenom primjenom NIV-a kod dijela bolesnika može se izbjeći invazivna ventilacija i njezini neželjeni učinci, čime se skraćuje vrijeme provedeno u Jedinici intenzivnog liječenja (JIL). U zadnjih dvadeset godina bilježi se učestalija primjena NIV-a, a povećava se i broj indikacija kod kojih se NIV pokazao kao metoda izbora. Tijekom pandemije COVID-19 NIV je postao vrlo popularan i kod bolesnika sa zatajenjem disanja u sklopu infekcije COVID-19 primjenjivan je diljem svijeta. Cilj rada je istaknuti nužnost respiracijskog nadzora za sigurnu primjenu NIV-a te upozoriti kliničare koji primjenjuju NIV u svakodnevnom radu na važnost uočavanja ubrzanog disanja i velikoga inspiracijskog napora kao kliničkih pokazatelja velikoga dišnoga rada. Neovisno o primarnom uzroku plućnoga oštećenja, veliki dišni rad dodatno pogoršava zatajenje disanja putem „samoozljeđivanja“ pluća (engl. patient self inflicted lung injury, P-SILI). Istaknuti su pokazatelji respiracijskog nadzora koji neizravno ukazuju na opasnost od P-SILI, a to su: veliki volumeni udisaja (engl. tidal volume, VT), negativni pomaci na krivulji alveolarnoga tlaka (engl. alveolar pressure, Paw), povećane vrijednosti okluzijskog tlaka u dišnome putu (P0.1) te visoke vrijednosti „driving“ tlaka. Smanjenje i kontroliranje velikoga dišnoga rada izazov je u svim situacijama u kojima bolesnik spontano diše, neovisno je li na neinvazivnoj ili invazivnoj potpori disanja. Temeljem do sada objavljenih spoznaja, kao i iz osobnih iskustava stečenih dugogodišnjom primjenom NIV-a u različitim kliničkim indikacijama, nastojali smo sažeti moguće načine kontrole povećanoga dišnog rada. Samo striktnim nadzorom respiracijskih pokazatelja, kontrolom povećanoga dišnog rada i poznavanjem NIV-a kao metode potpore disanja njegova primjena postaje sigurna, a eventualni neuspjeh NIV-a i potreba za prijelazom na invazivnu ventilaciju bit će na vrijeme prepoznata

Kako najbolje iskoristiti inteligentnu mehaničku ventilaciju za poboljšanje ishoda liječenja bolesnika u Jedinici intenzivne medicine?

Usprkos tomu što je mehanička ventilacija jedan od osnovnih postupaka spašavanja života u jedinicama intenzivne medicine, danas je nakon mnogih provedenih istraživanja jasno da pogrešno primijenjena mehanička ventilacija može napraviti značajnu štetu na ranije zdravim plućima ili pogoršati ozljedu bolesnih pluća te se u modernom pristupu ventilaciji maksimalno individualizira pristup, odnosno mehaničku ventilacija se individualno prilagođava stanju pluća pojedinog bolesnika. Usprkos tomu što postoje znanstveno dokazane metode smanjenja plućne ozljede, studije su pokazale da se u praksi kod velikog broja bolesnika one ne primjenjuju, odnosno ne mjere se parametri bitni za njihovo određivanje. Za individualizaciju ventilacije od intubacije do ekstubacije potrebno je nekoliko elementarnih alata kod kojih nam može pomoći umjetna inteligencija. To su incijalna optimizacija pozitivnog tlaka na kraju ekspirija, evaluacija i primjena manevara ponovog otvaranja kolabiranih dijelova pluća (engl. lung recruitment maneuver – RM), primjena moda ventilacije koji se može od udaha do udaha adaptirati na stanje bolesnikovih pluća, optimizacija plinova u krvi, optimizacija sinkronizacije bolesnika i ventilatora automatskim praćenjem krivulja mehaničke ventilacije te u konačnici alat za kvalitetnu procjenu sposobnosti bolesnika za odvajanje i samostalno disanje uz analizu potencijalnih problema kod odvajanja i njihove korekcije. To je moguće postići kombinacijom više alata, kao što su npr. alat tlak-volumen (engl. pressure – volume tool – PV-tool) uz ezofagealno mjerenje tlaka, adaptivna suportivna ventilacija (ASV) + Intellivent-ASV kao mod disanja, Intellisync+ te alat za olakšano odvajanje od respiratora (engl. quick weaning tool [QuickWean]) i test spontanog disanja (engl. spontaneous breathing trial – SBT) dostupni na uređajima za mehaničku ventilaciju. Kombinacijom ovih alata moguće je inicijalno optimizirati mehaničku ventilaciju, a zahvaljujući automatiziranoj pametnoj tehnologiji i individualizirati praktički svaki udah bolesnika te na minimum smanjiti vrijeme potrebno za pripremu odvajanja bolesnika od mehaničke ventilacije te ekstubaciju, a u konačnici i smanjiti smrtnost bolesnika na mehaničkoj ventilaciji

Hidden Carbapenem Resistance in OXA-48 and Extended-Spectrum β-Lactamase-Positive

The purpose of this study was to report the identification OXA-48 carbapenemase in seven extended-spectrum β-lactamase (ESBL)-positive Escherichia coli clinical isolates, fully susceptible to all carbapenems by disk diffusion and E-test methods, but with borderline minimal inhibitory concentration (MIC) values of ertapenem. This report points to the necessity for determination of carbapenem MICs in ESBL-positive E. coli isolates and additional phenotypic testing for carbapenemases in all isolates with borderline ertapenem MIC defined by EUCAST. The isolates showed a high level of resistance to expanded-spectrum cephalosporins because of the production of an additional ESBL belonging to CTX-M family. All isolates and their respective tranconjugants were found to possess L plasmid. Pulsed-field gel electrophoresis analysis revealed two clusters containing highly related isolates. The global spread of multidrug-resistant E. coli should be monitored closely because of the ability of isolates to rapidly obtain additional antibiotic resistance traits such as plasmid-mediated OXA-48 genes

Experiences and attitudes of medical professionals on treatment of end-of-life patients in intensive care units in the Republic of Croatia: a cross-sectional study

BACKGROUND: Decisions about limitations of life sustaining treatments (LST) are made for end-of-life patients in intensive care units (ICUs). The aim of this research was to explore the professional and ethical attitudes and experiences of medical professionals on treatment of end-of-life patients in ICUs in the Republic of Croatia. METHODS: A cross-sectional study was conducted among physicians and nurses working in surgical, medical, neurological, and multidisciplinary ICUs in the total of 9 hospitals throughout Croatia using a questionnaire with closed and open type questions. Exploratory factor analysis was conducted to reduce data to a smaller set of summary variables. Mann–Whitney U test was used to analyse the differences between two groups and Kruskal–Wallis tests were used to analyse the differences between more than two groups. RESULTS: Less than third of participants (29.2%) stated they were included in the decision-making process, and physicians are much more included than nurses (p < 0.001). Sixty two percent of participants stated that the decision-making process took place between physicians. Eighteen percent of participants stated that ‘do-not-attempt cardiopulmonary resuscitations’ orders were frequently made in their ICUs. A decision to withdraw inotropes and antibiotics was frequently made as stated by 22.4% and 19.9% of participants, respectively. Withholding/withdrawing of LST were ethically acceptable to 64.2% of participants. Thirty seven percent of participants thought there was a significant difference between withholding and withdrawing LST from an ethical standpoint. Seventy-nine percent of participants stated that a verbal or written decision made by a capable patient should be respected. Physicians were more inclined to respect patient’s wishes then nurses with high school education (p = 0.038). Nurses were more included in the decision-making process in neurological than in surgical, medical, or multidisciplinary ICUs (p < 0.001, p = 0.005, p = 0.023 respectively). Male participants in comparison to female (p = 0.002), and physicians in comparison to nurses with high school and college education (p < 0.001) displayed more liberal attitudes about LST limitation. CONCLUSIONS: DNACPR orders are not commonly made in Croatian ICUs, even though limitations of LST were found ethically acceptable by most of the participants. Attitudes of paternalistic and conservative nature were expected considering Croatia’s geographical location in Southern Europe. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12910-022-00752-5